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Musculoskeletal
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• History Taking
• QUIZ
• Examinations
• Assessments
• Feedback
GALS: Gait, arms, legs & spine
Screening Questions
• 1. Do you have any pain or stiffness in your
muscles, joints or back?
• 2. Can you dress yourself completely without
difficulty?
• 3. Can you walk up and down the stairs
without difficulty
History Taking
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Joint pain- SOCRATES, Distribution, symmetry
Morning stiffness
Joint swelling
Family history
Systemic disease
Injury
• Pmh- previous fractures, early menopause
• Dhx – steroid use
• Shx – alcohol
KNEE HISTORY
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Pain
A 'popping' or 'snapping' sound may suggest ligament rupture
Swelling:
RAPID (0-2 hours) - haemarthrosis, ACL or PCL ruputure / patella
dislocation
GRADUAL (6-24hrs) - meniscal tear
OVER 24hrs - no trauma – consider septic arthritis or inflammatory
arthritis
Locking or clicking suggests a loose body and may be due to
meniscal injury
Knee giving way suggests instability (eg ACL injury) or muscle
weakness
Previous history of knee injury, other past medical history,
occupation and level of exercise.
Acute knee injury
• Cartilage (meniscal)
• Ligament (MCL, LCL, CL, ACL)
• Fractures / dislocations (knee, distal femur /
proximal tib / fib / patella)
• Patella tendon rupture
Generalised Knee Pain
• Arthritis – monoarthritis, polyarthritis
• Crystal arthropaties – gout / pseudogout
• Seronegative arthropathies - Ank spond, Reiter’s,
Enteropathic arthritis, Psoriatic arthritis, Bechet’s,
Juvenile idiopathic arthritis
• Infective: septic arthritis, osteomyelitis
• Diseases of the bone: osteosarcoma (kids, pain with
activity, knee and proximal humerus)
• Referred pain from hip
• Rare: Rh fever, haemachromotosis, spontaneous
haemarthrosis in clotting disorders
Anterior Knee Pain
• Patellofemoral pain syndrome (chrondromalacia
patellae)
• Fat pad impingement: the infrapatellar fat pad
impinged between the patella and the femoral
condyle due to a direct blow to the knee. Treatment
includes patellar taping to relieve impingement.
• Patellofemoral instability (or recurrent patellar
subluxation): esp females - patellar hypermobility.
Treatment -bracing and crutches to reduce weightbearing. Exercises to strengthen or Surgery may be
required.
Other causes of anterior knee pain
• Referred pain from the hip, eg SUFE, Perthes'
disease.
• Osteochondritis dissecans.
• Bone tumour.
• Prepatellar bursitis / infrapatella bursitis
• Patellar stress fracture
• Osgood Schlatters disease
Lateral knee pain
• Iliotibial band friction syndrome:- friction between the IT band and the underlying lateral epicondyle
of the femur.
- Affects cyclists, dancers, long-distance runners, football players,
and military recruits.
- Tenderness over the lateral epicondyle of the femur 1-2 cm above
the lateral joint line. Flexion/extension of the knee can reproduce
symptoms.
- Treatment: NSAIDs, massage, stretching, muscle strengthening
and correction of predisposing factors (eg downhill running).
Steroid injection and surgery are rarely needed.
• Lateral meniscus problem (tear, degeneration, cyst).
• Other causes include: common peroneal nerve injury,
patellofemoral syndrome, OA, referred pain from hip / lumbar
spine
Medial Knee Pain
• Patellofemoral syndrome
• Medial meniscus problem (tear, degeneration,
cyst).
• Other causes include: tumour, referred pain
from the hip or the lumbar spine, MCL injury,
osteoarthritis.
Posterior Knee Pain
• Knee joint effusion
• Referred pain from lumbar spine or
patellofemoral joint
• PCL injury
• Bakers cyst
• DVT
• PVD
QUIZ
Genu Valgum
Genum varum
Basic GALS
• Wash hands, intro, consent
• 3 questions
• Ask patient to walk and turn
• Most MSK exams = look, feel, move (+
measure), special tests
GALS
• General
• The patient should be undressed to their
underwear and observed from the front, back
and sides, looking for any symmetry or
deformity (e.g. unequal leg length, kyphosis,
scoliosis, loss of lumbar lordosis).
• Ask the patient about any pain
Gait
• Ask the patient to walk, observe posture,
symmetry, legs and arm swinging.
Abnormal gaits
• painful hip
• Parkinson’s gait
• wide based gate
• Trendelenburg gait
• Antalgic gait
Arms
• Ask patient to hold out hands, palm down. Inspect the arms for obvious
abnormalities (e.g swelling, deformity,)
• Inspect skin or nail changes that may be associated with arthritis. (e.g.
psoriasis rash, nail pitting, skin changes of Raynaurd’s disease)
• Ask the patient to turn their hands over, with arms flexed at the elbow.
assessing the radioulnar joint which is commonly affected in RA
• Inspect the palms. Look for Dupuytren’s contracture and thenar waisting
• Ask the patient to make a tight fist. Check that the fingers can fully flex
into the palms
• Power-Ask the patient to grip two of your fingers
• Ask the patient to tip each finger in turn onto the tip of the thumb. This
assesses opposition of the thumb and fine movements which are often
limited in RA
• Squeeze across hand from the 2nd to 5th MCP joints- Assess for tenderness
• Ask patients to put their hands behind their head, pressing the elbows
back. This movement assesses abduction and external rotation at the
shoulder and flexion at the elbows and is of functional importance in
combing hair.
Legs
• Patient lying supine on the couch, inspect for flexion
deformity at the hip or knee.
• Passively flex the hip and knee with a hand placed over the
knee.
• Assess knee flexion whilst feeling for crepitus and assessing
hip flexion.
• Passively internally rotate the hip with hip and knee still flexed
(both at 90º). Internal rotation is the first movement to
become restricted in hip disease.
• Ask patient to flex, extend, invert and evert the ankle.
Assesses the tibiotalar movements (affected by OA) and
subtalar movements affected by RA.
• Squeeze across the foot at the level of the MTP joints. Assess
for tenderness.
Spine
• Inspect
• Ask patient to put their ear on the same side
keeping the shoulder still to assess lateral flexion
of the cervical spine, which is the first movement
to become restricted in degenerative or
inflammatory disease.
• Place two of your fingers over adjacent spinous
processes in the lumbar region and ask the
patient to bend over and touch their toes. Your
fingers should move apart.
Record in a table
A = APPEARANCE
M = MOVEMENT
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Assessments
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